198600265-7-24-2023-28-AS-JKAN-CU2PJJ-20230724112137

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600265
Report Date: 07/24/2023
Date Signed: 07/24/2023 11:21:41 AM

Document Has Been Signed on 07/24/2023 11:21 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	ERNIE'S PLACE		FACILITY NUMBER:	198600265
ADMINISTRATOR:	LAN LY		FACILITY TYPE:	735
ADDRESS:	630 N. NICHOLSON		TELEPHONE:	(626) 280-7205
CITY:	MONTEREY PARK	STATE: CA	ZIP CODE:	91755
CAPACITY: 6		CENSUS: 6	DATE:	07/24/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Associate Director / Alexander Stott		TIME COMPLETED:	11:45 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced case management visit to this facility. Upon arriving at the facility, LPA met with Associate Director / Alexander Stott who assisted with the visit. LPA explained the purpose of today's visit is to follow up on two incidents which occurred in April of 2023, involving Client 1 (C1) and to ensure that Unusual Incident/Injury Reports were submitted to Community Care Licensing (CCL), as required by Title 22 Regulations / Reporting Requirements. The first incident involving C1 occurred on 4/20/23, at 2:30pm. C1 was arriving home from an outing in a staff vehicle and stepped out of the vehicle on the passenger side and closed the door. As soon as C1 closed the door, C1 stiffened up and fell backward landing on his back. C1 hit the back of his head on the cement, causing bleeding. Staffed called for assistance, placed a towel on the back of C1's head and called 911. C1 was transported to Monterey Park Hospital where he had lab work done and a CT scan. The results of the lab work and CT scan were negative. C1 received 9 staples on the back of his head and was discharged back to the facility at 5pm. The second incident occurred on 4/20/23, at 6:30pm. C1 was being assisted with a shower by staff and while sitting in the chair, C1 began to project vomit. Staff called for assistance while C1 continued to vomit several times on the shower floor. C1 tried to stand up and fell forward, hitting his forehead on the floor. He was responsive and remained lying down as staff instructed him to do so due to the visible trauma. C1 sustained a 3 inch gash on his forehead. Staff applied direct pressure using a paper towel and a wash cloth and called 911 for assistance. Upon the arrival of the paramedics, C1 became unresponsive and was transported to LAC+USC where he received 5 stitches in the middle of the forehead. A CT scan was done which also resulted in negative findings. C1 was seen by a neurologist who discussed the possibility of adjusting his medications. C1 was admitted for 24 hour observation, due to hospital protocol. C1 was discharged from LAC+USC on 4/21/23, at 12:30pm with aftercare instructions. Per the Associate Director, C1 was taken to Garfield Medical Center on 5/2/23, where they removed the staples and the stitches.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ERNIE'S PLACE	FACILITY NUMBER: 198600265
	VISIT DATE: 07/24/2023

NARRATIVE

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The Eastern Los Angeles Regional Center (ELARC) conducted an investigation regarding both incidents involving C1. There was no immediate danger found to the residents in care and ELARC issued a Letter of Findings and Recommendation on 7/10/23. The findings were listed as Unsubstantiated. Per the Associate Director, the recommendations requested by ELARC were completed within the time-frame requested.

During today's visit, LPA took a quick tour of the facility and spoke with clients present at the facility, including C1. C1 was observed in his room doing well and watching TV.

After reviewing the file of C1, LPA verified that two separate Unusual Incident/Injury Reports were submitted to CCL on 5/21/23, as required by Title 22 Regulations / Reporting Requirements. No deficiencies are being cited.

An exit interview was conducted and a copy of this report was provided to the Associate Director.

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Joe Katrdzhyan
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

LIC809 (FAS) - (06/04)

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